Our last day. Dr. Nichter makes rounds to see the progress of patients.

Elena and Lucy lecture about cleft lip/palate and recovery to a full house

It is the last day of Surgery for the Plasticos Team in Siem Reap, Cambodia. When the medical instruments are cleaned and put away, and each patient is in the ward- recovering, we will have performed more than 50 surgical procedures on 20 patients. This is not the usual trip where one procedure or maybe two are performed. Rather because of the complexity of the cases, the severe disfigurement and loss of large portions of their anatomy required this number of individual surgical approaches. The teaching opportunity of each case also resulted in less patients then say the repair of a cleft lip. Although other non-profit surgical teams travel abroad in hopes to operate on as many individuals as possible, Plasticos is unique in that, rather focusing on the quantity, we emphasize the transfer of information to the local staff. Our metric of success if based on the new found technical skills the local surgeons will competently have so that the same work can be accomplished in our absence. This is one of the main objectives of the Plasticos Foundation- to leave behind an indispensable contribution- the knowledge, and capable hands to continue performing the complicated and intricate reconstructive plastic surgery procedures. In this mission to Cambodia this included cases such as, severe burn reconstruction and complex congenital hand reconstruction. The cases the local surgeons chose were cases that they would not normally attempt on their own.

A typical day in the OR. (from left to right: Chris, Dr. Sar Vuthy, Jessie, Dr. Nichter, Elena and Mia)

The Plasticos Team not only has formed a strong bond with the patients and families, but has worked side by side with the local medical staff, in-trusting the surgeons and nurses with their years and years of experience and skillful insight. In speaking with a number of the local physicians and nurses, we are happy to hear their thankful response and enthusiasm for the Plasticos Team helping the children of Cambodia and welcome the foundation back with open arms.

I must confess something. I’ve developed a crush on a Khmer boy named Boran Buon. He was admitted to the children’s ward for a pre op about half hour ago. What struck me about him was that since the first clinic day, he was smiling. He was the only kid at the prescreening day who looked genuinely happy instead of confused or frightened. At 14 years old, Boran is one of the few older children having surgery. Unlike most other children, who are scared going into and coming out of surgery, Boran is old enough to understand that this surgery could change his life forever. In a couple hours, he will wake up with a functional hand.

Boran, just minutes before surgery. The look on his face says it all.

While learning to take his first steps at 1 year old, Boran tripped and his right hand fell into a pot of boiling sugar being cooked over an open fire. This burned and fused his fingers. For 13 years, he has lived with a non-functional hand. Today, that may be changed. Just minutes before surgery, he looks like the happiest boy on earth.

Boran’s mother had heard that our team was coming from a radio announcement. She and her son have traveled 120 miles for the chance to be selected for surgery. Their bus ride cost them $5 for a one-way ticket. That’s almost the average weekly wage in Cambodia.

I am ecstatic for him, and I truly cannot wait to see him come out of surgery.

Our 3rd Day at the Angkor Hospital for Children demonstrated the reality of delivering medical care in Cambodia. A young boy was brought to the hospital the previous day with acute abdominal pain, and during the following 24 hours, the child rapidly decompensated and went into septic shock. They were unable to obtain a blood pressure greater than 50/30 despite an epinephrine infusion. Eventually, the child was considered stable enough to be brought to the operating room for an exploratory laparotomy. Prior to surgery, the child experienced a cardiac arrest and required CPR. Once a pulse was re-established, the surgery continued. During the 3 hour operation, the child had another cardiac arrest, and was revived again. The child was brought to the ICU following the surgery, and no clear diagnosis for the septic shock and multi-organ failure was ascertained despite the attempted therapy, the young boy died a few hours later. I was later told that during the rainy season, this type of case occurs every few weeks, and often the underlying cause of the massive systemic infection is never known. It is just a part of the harsh reality of medical care in an underserved nation…

Despite the many reconstructive surgical missions that I have been on, I always dread the haunting feelings the patient and I experience when I am unable to help. This by far is the hardest situation that I and other Plasticos Team members experience. I am not referring to patients with problems requiring the talents of different surgical disciplines or even cases I can do with specialty equipment or intensive facilities back at home. What I am referring to are children with devastating deformities/injuries that we not only can takecare of but can also teach the local surgeons how to perform the same after we have left. . After all, this is the mission of Plasticos Foundation. These are children that because of time limitations are left when our trip is finished. Even worse are children unable to have surgery because of other issues of fate. An example of this happened just this morning.

Ly Math is a 3-year-old engaging boy with the weight of the world upon him or so it seems. Actually, he looks like there is a weight pulling his right lower eyelid, cheek, jaw line and neck onto his chest. In reality, a mosquito net used to prevent Malaria and Dengue Fever (rampant in this area) caught on fire from an oil lantern and burned his skin off. The healing wound contracted pulling forcefully down his facial tissues via thick deforming scar tissue. Behind this deformity is an attractive boy with playful eyes though somewhat apprehensive because of his appearance. His right eyelid is pulled down so a tear always lingers but does not fall. He is unable to look up to see his mom’s face without arching his back Food and liquids come out of the corner of his mouth that is pulled down when eating.. Quite simply, it is impossible for Ly to be just a little boy who runs and plays with other children. That is the way life is supposed to be, isn’t it?

Because of the complexity of his deformity, this could not be corrected by local surgeons. One day his mother listened to the radio announcement in her village a month prior to our arrival Last week, Mother and son started their arduous journey to see us. This was the lucky miracle they had prayed for! Or so they thought. Of the many children we screened for surgery this boy would have the most dramatic improvement with immediate correction of this debilitating injury. It was also a great chance to demonstrate some advanced surgical techniques to the dexterous and bright Cambodian surgeons we are working with. He was scheduled for surgery first thing Wednesday morning. All of our team were excited to be a part of his cure. Despite his young age and attendant fear of surgery by strange doctors and nurses speaking a foreign tongue, you could tell he wanted this more than anything. Anything to be free from the restrictive bonds of deformity preventing him from being like any other boy.

Ly Math, on the day of surgery with a 103 F temperature.

Ly was admitted the night prior to surgery – Our team arrived bright and early the next morning ready to erase his inequity of fate only to find out that he had a temperature of over 103 F temperature previous night. The hospital pediatricians tentatively diagnosed Influenza Virus (Flu) but could not rule out Dengue fever. The bottom line is that this fever- whatever the source- made it too dangerous to operate on him. We observed him for another day but alas more of the same. Painfully, the doctors and nurses of Plasticos and the Ankor Watt Childrens hospital shared in the devastating news to his Mom and Ly. In short, the wings of ours and this little boys desires were cut by the harsh shears of reality. We did our best to tell them not to give up hope and that we would return one day; that they should listen to the radio for a similar announcement. It is hard to imagine how cruel fate can be and what must be going through their minds. How would I have coped if this was my son?

I shall never forget his face. With luck our paths will meet more auspiciously next time. He deserves better.

So does the baby on a bed in the hallway with a cleft lip who developed pneumonia at just the wrong time, and the little girl with contracted burn fingers who developed a skin abscess the day prior to surgery and so on………

9 ‘o clock AM. It is a beautiful day at the Angkor Children’s hospital. The blazing sun bakes my skin, sticky from the engulfing, inescapable humidity. Step into the screening room. Ahhhh – “the refuge,” as Paul calls it – at 86 degrees Fahrenheit. On the other side of the double doors stand 60 children and their mothers in the heat of the outside sun. Some have traveled far to come to the hospital. For many, the cost of getting here is more than the average weekly wage; a couple hours in the sun is nothing. Eyes look through the glass windows in the double doors – mothers with happy faces, children with curiosity. These children have been pre-selected by the hospital for our team.

Jessie and I set up our laptop and patient charting station. On the other side of our desk is Paul (our pediatrician), and in front of him are Dr. Nichter and Dr. Vann Thy (Assistant Chief of Surgery at the hospital), and to the right Chris (our anesthesiologist). We all set up our arbitrary “stations.” And then the screening process begins.

Children walk in, sometimes not knowing what to expect. Some are hesitant; some little ones – not understanding what is happening – cry; most children have serious, somber expressions, as if seeing a doctor confirms there is something wrong with them.

Fast forward a couple hours. A shirtless quiet 3-year-old boy with a buzzed haircut holding his mother’s hand steps into the screening room. His name is Ly Math. His mother motions for him to sit in the chair facing Drs. Nichter and Vann Thy. He obeys, then turns around and looks at her, hiding half his face behind the backside of the chair. Dr. Nichter asks to turn him around so that he can begin examining him. From the left, Ly looks like a soft, impressionable, innocent little child. His right side is stretched and immovable, drastically limiting facial mobility. A brief flash in a fire at 1 year old, changed his life forever. The bottom of his chin is attached to his shoulder, making it impossible to turn his head. Should he have to see something on his side, he’ll have to turn his entire body. The bottom right corner of his mouth is pulled down and is permanently open (probably limiting chewing capability). The bottom of right eye –stretched so that the white of his eye made more visible. Facial mobility in the right side of his face affects facial mobility on the left. Therefore, Ly looks stoic — hard to read. Yet his physical responses give clues to his thoughts. He listens to Dr. Nichter talk – his eyes searching and curious.

On to Paul, who has a wonderful — almost fatherly way — with kids. Paul checks to see if he has any allergies, is on any medication, what his past surgical history is like and so on. He is a go. Cleared for surgery.

I then walk him over to Jessie, who takes his pre op photo. I motion him to the space in front of the camera. At the sight of the huge, wide lens, he stops. His hesitation, a window into his thoughts. He looks up at his mom and she gives him a reassuring look. He walks to his place, and I am surprised by how small he is. Perplexed, I can’t tell what he’s thinking. His face says nothing. But something about him seems older than his age. He’s holding something back…such restraint, control, acute awareness for a young boy. I smile at him, hoping to convey that he will be fine, that everything will be all right.

Then, suddenly, a teardrop lands on his right cheek and runs down his chest.

And another one.

And another one.

Each time, heavier; each one, bigger. His scarred right lower lid is stretched down, creating no space for tears to pool up, so they fall out of his eyes. Yet no words or bodily movements that would indicate that anything is wrong. He stands there, in front of the camera, tears rolling down his face and chest. I can no longer force a smile and I feel my throat swell, my face warm and my eyes water. After pictures are taken, his mom holds his hand and walks out of the screening area. I walk back to my desk and Paul asks me if I heard what Ly asked him. I didn’t. The boy asked if he was going to die, because that is what he thinks happens to people in the hospital. At 3 years old, Ly has experienced more than is bearable.

Yesterday, with the help of two Cambodian surgeons, I unlocked the hidden hand of a quiet and beautiful 7 year old girl named Samuth . In the Cambodian language of Khmer, the word for beautiful is pronounced Sa’ad. The irony and double entendre was that her condition was Sad. Her hand and wrist were bent backward 180 degrees. Essentially, her dislocated wrist and fingers were trapped and hidden within her forearm massive burn scar. Years ago, as a toddler, she fell into the open cooking fire. Most of the world cooks that way and the number of burned and deformed children we examined this trip with a similar story attests to that fact.

After just an hour and a half, her wrist and fingers were reduced to a normal position by rotating her skin this way and that and taking a large skin graft whose scar we hid in the crease of her upper thigh. From a functional standpoint her arm went from useless and grotesque to functional in less time then it takes to see a movie in the United States. I am constantly amazed by this fact and often find my mind wandering about how little time it takes to transform a life by a simple deed. Today on rounds I was curious to see how much discomfort she was in after such a dramatic surgery. Even at this tender age, she must have realized the significance of her second chance at life. As I approached her bed, instead of crying, she knowingly looked into my eyes and eked out a half smile. This young Cambodian child like so many others, the Plasticos team has treated has certainly added to ones life’s perspective: both theirs and ours. The next patient is asleep. Time for the next chance to help both patient and giver alike.

Today is our fourth day at the Angkor Hospital for Children. The sky is overcast threatening rain as the Plasticos team walk to the Hospital already at 7:30 AM, the heat and humidity are stifling as we enter a side door into a hallway, past the surgical ward to the OT (operating theater). An 8-month-old baby is asleep next to his sleeping mother. Their bed, without sheets, is in the hallway. He stirs in his sleep, pulling at the tube through his nose. He has pneumonia but is doing well. Look back from the OT door and to the hallways right and left are beds occupied by children overflowing the wards, and now overflowing the hallway. It is the raining season – therefore, dengue fever time.

The fourth day, now 11 AM. Samuth, a 3 year old has been in the operating room now for one hour, 2-3 hours left to go. Plasticos and the Cambodian surgeons are working to reconstruct her hand. Her brown eyes, while awaiting surgery, seemed very sad. Looking at the extensive burn of her left hand and arm, we wonder if she was as hopeful for a good result as all here. Only time will tell.